MEDICARE: MRS. JENNIFER RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R047014-1	NY
2	1041S0200X	School Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659664217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER RUSSELL

Provider Business Mailing Address
First Line	:	85 SHELL EDGE DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-4356
Country	:	US
Telephone Number	:	585-359-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 SHELL EDGE DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-4356
Country	:	US
Telephone Number	:	585-359-5400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	05/18/2011

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